Central Cord Syndrome

Central Cord Syndrome (CCS) is an injury to the cervical area of the spinal cord.
The injury results in extensive motor weakness, usually worse in the upper extremities
than the lower. The injury occurs when the neck is hyper-extended, that is, extends
further than usual or normal, usually the result of a blow to the head. The end
result is a localized injury to the spinal cord.

Mechanism and Causes of Injury

CCS occurs typically in patients that hyperextension occurs. The spinal cord
is squeezed or pinched between anterior (front) cervical body and the posterior
intraspinal canal ligament, called the ligamentum flavum. The ligamentum flavum
is a strong ligament that connects the laminae of the vertebrae. It serves to
protect the neural elements and the spinal cord and stabilize the spine so that
excessive motion between the vertebral bodies does not occur.

The injury occurs as a result of anterior and posterior compression of the spinal
cord, leading to edema (swelling), hemorrhage (bleeding) or ischemia (lack of
blood flow) to the central portion of the spinal cord. The site of most injuries
is in the mid-to-lower cervical cord. Due to the anatomical location of the nerves
that serve the arms and legs, the arms are affected more so than the legs. This
results in the weakness in the arms being worse than the legs.

Patients are typically left with motor weakness of the upper extremities and
lesser involvement of the lower extremities. A varying degree of sensory loss
below the level of the lesion and bladder symptoms (urinary retention) may both
occur.

Incidence

This syndrome more commonly affects patients age 50 and older who have sustained
a cervical hyperextension injury.

CCS may occur in patients of any age and is seen in athletes who present with
not only hyperextension injuries to their neck but may also have ruptured discs.
These ruptured discs cause compression of the front (anterior) part of he spinal
cord. CCS affects males more frequently than females.

Diagnosis

Evaluation of the patient includes a complete history, a thorough neurological
exam, MRI and CT of the cervical spine, and cervical spine x-rays including supervised
flexion and extension x-rays.

Magnetic resonance imaging (MRI): A diagnostic test that
produces three-dimensional images of body structures using powerful magnets and
computer technology; can show direct evidence of spinal cord impingement from
bone, disc, or hematoma.

Computed tomography scan (CT or CAT scan): A diagnostic
image created after a computer reads x-rays; can show the shape and size of the
spinal canal, its contents, and the structures around it.

X-ray: Application of radiation to produce a film or picture
of a part of the body can show the structure of the vertebrae and the outline
of the joints. X-rays of the spine delineate fractures and dislocations, as well
as the degree and extent of spondylitic changes. Flexion/extension views assist
in evaluation of ligamentous stability.

Surgical Treatment

Urgent surgery is not usually necessary unless there is significant pressure
on the spinal cord. Prior to the CT-MRI era, surgical intervention was thought
to be more harmful because of the risk of injuring a swollen cervical cord and
making the injury worse. However, with advanced imaging technology such as CT
and MRI, patients with compression of the spinal cord secondary to traumatic
herniated discs and other lesions can be quickly diagnosed and surgically decompressed.
Many times, surgery is usually not done until the patient has made the best recovery
they can. Reassessment at that time may lead to surgery depending on the underlying
cause. If there is significant motor weakness after a period of recovery, or
neurological deterioration or spinal instability, then surgical intervention
may be considered.

Nonsurgical Treatment

Nonsurgical treatment consists of immobilization of the neck with a cervical
orthosis (such as a cervical collar), steroids (unless contraindicated), and
rehabilitation with physical and occupational therapy.

Outcome

Many patients with CCS make spontaneous recovery of motor function while others
experience considerable recovery in the first six weeks post injury.

If the underlying cause is edema, recovery may occur relatively soon after an
initial phase of motor paralysis or pareses. Leg function usually returns first,
followed by bladder control and then arm function. Hand movement and finger dexterity
improves last. If the central lesion is caused by hemorrhage or ischemia, then
recovery is less likely and the prognosis is more devastating.
The prognosis for CCS in younger patients is favorable. Within a short time,
a majority of younger patients recover and regain the ability to ambulate and
perform daily living activities. However, in elderly patients the prognosis is
not as favorable, with or without surgical intervention.

This information is provided courtesy of the American Association of Neurological
Surgeons, www.neurosurgerytoday.org, and edited by Johnny Hudson, NP. Updated
October 2008